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Training in Robotic Surgery

The UAB Medicine Robotic Surgery Program is one of the largest in the Southeast and has the largest surgical volume in the country, with nearly 25 surgeons using the da Vinci robot to perform almost 1,000 surgeries each year. UAB Robotic Surgery includes several fellowship-trained subspecialists who have received the maximum training in their field. UAB regularly sets new surgical standards and attracts hundreds of surgeons from around the world for observation and educational sessions involving the da Vinci robot.

Joining the show to discuss training in robotic surgery at UAB Medicine is Dr. Kenneth Hyun-Chung Kim. He is an associate professor who specializes in Obstetrics & Gynecology and Gynecologic Oncology at UAB Medicine.

For more information about our Surgical Training Programs, explore the webpages below.

Dr. Kim does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity.

Transcription:

Melanie Cole (Host): UAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education, designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category one credit. To collect credit, please visit UAB medicine.org/medcast and complete the episode’s post-test.

Robotic surgical devices have developed beyond the investigational stage and are now routinely used in many more types of surgery, but what’s involved in training for physicians? My guest today is Dr. Kenneth H. Kim. He’s associate professor who specializes in gynecologic oncology and the Director of Robotic Surgical Education and Training at UAB Medicine. Welcome to the show Dr. Kim. So, tell us a little bit about training for robotic surgery. How should that be accomplished and what’s the process for credentialing? What are you doing there at UAB?

Dr. Kenneth Hyun-Chung Kim, MD (Guest): So, traditionally, most programs haven’t been used to training physicians in robotic surgery and it has kind of come about and evolved over the years. Some programs have a specific curriculum, some programs kind of just teach their trainees on the fly. So, coming back to UAB, one of the first things that I wanted to do was revamp our whole entire robotics curriculum starting with the GYN curriculum and then expanding into all other robotic surgical fields. So, at a traditional program or many, many programs, if there is any sort of trainee training; it usually happens once a year if at all, and it’s usually based on subjective Likert scales, there is nothing objective about it. But if you think about surgery, it’s a lot like learning a sport and playing a sport. There are techniques involved and then you learn these techniques and then when you get to game time, then you apply the techniques and skills that you learned to win the game. So, surgery is very similar. Like you have all these surgical techniques to learn and when it comes to the OR, and a live operating room with a live patient; then that’s when you have to apply all the techniques and skills in a logical manner to get the surgical procedure done safely and efficiently for the patient.

In the past, we haven’t really been able to do as much of the metrics and things like that that other – you know obviously sports fields do like NFL and things like that. They have video review, they have pattern recognition, and things like that. But recently, we have been able to collaborate with a number of partners to develop technology that really does a lot of this. Simulation, motion based analysis and things like that. And whereas many other programs may only have once a year training; for my own residents, we will run this training every three to four months across all residents, across all years, so that there is no degradation of skill over time and so that they can build upon the skills so that when they get to the operating room, they learn – they have already learned the system of the robot – the surgical robot and then they can focus on the actual procedural steps.

Before, without any sort of teaching, they would come to the operating room and they would have to contend with basically two learning curves. They would have to learn how to use the robot as well as how to learn the procedure. But we can do better than that now, with simulation and with motion based analysis we can number one; get them familiar with the robotic systems, so they don’t have to learn how to use that in the process and number two; now with procedural based simulation, we can actually teach them actual procedures while doing the simulation that is much more safer and much more efficient for training these physicians for the future.

Melanie: Do you see any limits for clinical applications for robotic surgery? Are there any kind of off limits service lines?

Dr. Kim: Well, that’s probably not a question that I can answer right now because as technologies are always going to advance and evolve and so especially with the training program; you have to really keep in mind that technology is kind of ephemeral and as technology improves and advances; you also have to evolve and advance with the technology, so you don’t have things that get outdated or archaic. So, with the robotic system, there are new procedures that they try to apply to obviously in a safe manner that undergoes peer review and things like that. But when residents and trainees graduate from any given training program, every single hospital in the country does their credentialing differently. When our graduates complete their training here, when they graduate from residency or fellowship; they have a letter that says how many cases they did. They have a case list outline of all the cases they did and so that it is much easier for our trainees once they graduate to actually get credentialed in many hospitals across the country.

Melanie: So do you feel the costs are justified for setting up these kinds of programs? Tell us how you guys are using this program as a beta site for other hospitals around the world.

Dr. Kim: Right, so we are still, this is – a lot of this technology is brand new, so we to first see the feasibility and see if it makes a difference in the learning curve; which so far it has, and we have a lot of data that we are going to publish that outlines how the learning curve is actually really quickened by this process. We are lucky because of our partnering that we have some technologies that don’t exist anywhere else in the world. We have a simulator that has multiple procedural based surgical procedures as well as simulations that are not available to other programs currently and then because of that and because of our partnership; we are able to beta test virtually all training and educational robotic surgical educational and training tools that come out to help with the evolution of training and making it more efficient and hopefully make it more cost effective. The hope is and the second phase of some of our studies, hopefully if we can do it is to once we have implemented the program, which we are doing right now, across all specialties; is to see if it translates to better cost effectiveness for the hospital. Is the patient in the operating room less? Are there less complications and things like that, that are hopefully going to come out from some of the studies that we will hopefully be able to do.

Melanie: How are you evaluating the impact of this program on outcomes? How are you doing that?

Dr. Kim: Well we haven’t yet. We are first getting the feasibility right now, but the feasibility is based on a couple of different metrics that we measure the residents on. We have again, hi-fidelity simulations and we can get metrics on every single thing they do. How many times they move their left arm, how many times they move their right arm. How many times and how much they move the camera. How many specific motions it required to complete a task or procedure. And then we can also graph recording graph in three-dimensional space all of the motions that their left hand, their right hand, the camera and other points of interest made throughout the procedure. We can graph that and then we can show, actually physically show the learning curve from a novice to an expert and how these graphs shrink up and become much more efficient. There is less conflict. There is less number of discrete motions that are required to complete a specific procedure and over time, it doesn’t take – we have learned that it doesn’t take them that long to show these improvements. So, hopefully this will continue on all levels.

Melanie: What about for the surgeon themselves? Is there a physician selection criteria for you – for your education program in teaching this and as far as you said, how many times they move their left arm or their right arm. Are there certain parameters that you are going to take into account when you are looking at this criteria for physicians?

Dr. Kim: So, currently with the trainees; this is the first time this has ever been done really at all. So, we are actually defining the metrics for how a surgeon goes from kind of a novice level to a more expert level and beyond. So, from that, then we can hopefully reproduce it and then use that as a guide for future training. We have been able to identify residents who are have an innate surgical vision and then it really allows us to individualize their education as surgeons because then we know what they are capable of, what they are not capable of and how to get them to where they need to be. As educators, we have a responsibility and when they come to a surgical residency to really train them to be competent surgeons and tools like this that are much more quantitative and much more objective allow us to do that much more efficiently and get them to where they need to be in a much more efficient manner while also individualizing to each of the trainees as they go through.

Melanie: What about comfort for the surgical residents? We always hear that it gives better effects for the patient and better outcomes, but what about for the surgeon themselves and robotic surgery?

Dr. Kim: Yeah, it’s definitely much more ergonomically designed with the current system that we have. There are other surgical systems that are going to come to market that have been recently FDA approved and more will come to market in the next couple years. The current systems that are available are much more ergonomically designed and much better for surgeon comfort than traditional laparoscopy. Which can hopefully lead to longer – increased longevity for surgeons and less issues with shoulder pain, back pain, neck pain and things like that. We did actually do some studies on that at my previous institution and to look at optimal height, optimal positioning and things like that for robotic surgery and the decrease in kind of surgeon pain or soreness.

Melanie: Well ergonomics is certainly a big part of this picture I would think. So, what are some of the important unanswered questions in robotic surgery? And what direction do you think future research should take? Or what do you think it will take?

Dr. Kim: Well, there’s a lot of research going on with computer assisted types of imaging or types of minimally invasive techniques and procedures. Robotic surgery is technically just computer assisted laparoscopy. But some of this technology can probably be applied to other – in other manners to do other minimally invasive or increasingly minimally invasive type procedures which is going to be better our patients and less morbid with less complications and things like that. So, as we progress with these types of technologies and the research of how to apply them; obviously the other thing is going to be to try to contain the cost.

Melanie: So, now what about the different systems out there? We have all heard about da Vinci and there is also Zeus and how do you decide as the educator, what systems that you are going to train your residents to use?

Dr. Kim: Well, right now it is easy because right now we only have the da Vinci right now, but as other – as these other robotic surgical systems come about, we will obviously have to vet them and apply them and see if they are appropriate and safe with similar outcomes for in our case, GYN cancer patients and other fields so that they have similar outcomes. That’s really the crux of the matter. But ultimately, at the root, all of these robotic systems are really just a tool for us to get the job done and it’s just a matter of decision making and making sure you are selecting the right tool to get the right procedure done on the right patient, on a case by case basis.

Melanie: Dr. Kim, in summary, tell other physicians what you would like them to know about the robotic surgery training program at UAB Medicine and when to refer.

Dr. Kim: Yeah, so right now, as far as training, we probably have the most advanced robotic surgical education and training curriculum that exists and because we are a beta site for future technologies; we are really ahead of the curve, years ahead of the curve for most programs. At UAB, we try to pride ourselves on that, so we are going to try to continue to push the envelope and push the curve and help adapt and evolve as the technology does and hopefully make an impact for patients is what I would probably say about us right now.

Melanie: Tell us about your team. Why is UAB so great to work with?

Dr. Kim: You know, from top to bottom, which a lot of my robotic colleagues will also say whether it is Dr. Porterfield or Dr. Nicks from general surgery and urology, some of my own partners in GYN oncology; they will say from top to bottom at UAB from the CFO down to our robotic coordinators and our robotic operating room nurses; everyone is completely invested in the success of our program. Everyone is very collaborative and respectful of each other. We have a very – we have very much a team based approach even across multiple specialties. Our whole program and our departments are really unique in that we communicate constantly with our robotic urologist, with our robotic colorectal surgeons, our robotic thoracic surgeons, our robotic ENT surgeons; all of the robotic surgeons communicate, and they understand that we want to as a whole, be leaders and to do that we don’t want to sequester ourselves in siloes and not work together. Because the sum of our whole is going to be greater than each of our parts separately. So, we really believe that each of the personnel from top to bottom is really invested and I think that translates to why we have such a successful program, not just in robotics, but in a lot of our clinical operations in general.

Melanie: Thank you so much for being with us today, Dr. Kim. What great information. A community physician can refer a patient to UAB Medicine by calling the Mist line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.uabmedicine.org/physician. That’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.